In a medical malpractice case, plaintiffs and defendants alike rely heavily on the medical records to piece together what did and didn't happen. In medical school, they taught me that if it wasn't charted, it wasn't done. In medical malpractice law, I've learned that just because something is charted doesn't mean it was done correctly  or even done at all.

Lawyers have been dealing with altered patient records for as long as they have been suing physicians. Rarely is a physician better at matching pen colors and handwriting than the plaintiff's attorney will be at spotting such an action. However, the days of handwritten records are mostly in the past.

The electronic medical record (EMR) is touted as one of the best new additions to medical record keeping due to its time-saving abilities, its ease of transferring records and its tailor-made templates, which should make it all but impossible to fail to document an important step in patient care. And, yes, recording the detailed care of the patient can be your best friend in the event of a malpractice case. However, some of the very features that make the EMR so quick and easy to use make it potentially dangerous with a couple of pitfalls.

Pitfall: Altering records after the factA physician may use the EMR system perfectly  until she gets the whiff of a potential lawsuit. Take, for example, the gynecologist who places an intrauterine device (IUD) into a patient  a procedure she has performed hundreds of times. The doctor is well-versed with the EMR and chooses to write a freehand note in the chart instead of using a ready-made template designed for IUD insertion. She writes that the uterus sounded to 9.5 cm prior to placement, and that the patient complained of pain upon insertion. Despite these abnormalities, the doctor doesn't suspect perforation of the uterus and sends the patient home.

New to Outpatient Surgery Magazine?Sign-up to continue reading this article.Register Now